Attachment 4 – Work Clearance Form
THIS IS NOT A PERMIT
Date:
ALL SECTIONS MUST BE COMPLETED.
THIS FORM MUST BE REVIEWED AND
ACKNOWLEDGED BY THE SITE REPRESENTATIVE.
THIS FORM IS VALID FOR A MAXIMUM OF 1 DAY.
Person Undertaking Work:
1.
Job/Work Order No.
Company:
Permit No:
Permit Expiration Date:
WORK DESCRIPTION (Please use BLOCK CAPITALS except for signatures)
Site Address:
Detail of Proposed Work for the Day:
ARE YOU GOING TO PERFORM ONE OR MORE OF THE FOLLOWING ACTIVITIES?
Any “Yes” answer requires a Permit and a SWMS. Consult your
Permit Issuer before starting any work.
Yes
No
Hot work in hazardous area
Confined Space Entry
Any “Yes” answer requires a SWMS or JSA or SOP. This activity is required to be
undertaken under the supervision of a Z prequalified contractor or Mini Tankers
operators or Retail Site Retailer, and in accordance with their HSSE Management
Plan. Consult your supervisor if you are unaware of whether or not your company
is prequalified.
Excavations >/= 1.5 metres
Live Electrical Work
Yes
Abnormal work or maintenance
Restricted Space
Hazardous substance exposure -asbestos, lead
Excavations between 0.5 or greater (not permitable)
Energized high pressure work - hydrant lines
High pressure system work – compressed air
Live energized product line work
Work at Heights between 0.5 metres and 1.8 metres
Work at height greater than 1.8 metres
Non-powered hoist use involving a suspended load
Shop roof construction and/or installation
Work off site in roadways
Canopy construction and/or installation
Work on low voltage equipment and circuits
Working on single skin canopies
Erection of structures
Working on non-trafficable secondary surface
Pump out of product tanks
Tank removal and/or install
Drilling of monitoring wells or soil borings
Demolition – excluding soft strip out
Hazardous substance exposure of medium residual risk
Crane work (excluding deliveries)
Hot work outside of the hazardous zone
2.
No
CONTROL MEASURES TO BE TAKEN - ALL WORK (Contractor must ensure the work area is safe)
No work is to start until the controls have been identified
Yes
No
N/A
Any “No” answer requires details in the space below.
Can safe access be maintained to and from and around the work area?
Have you checked whether there are other activities being carried out that
may affect your work / safety?
Have you informed others that may be affected by your work?
Are suitable fire extinguishers available within work area?
Will barriers be erected around work area?
Have you planned the job to avoid extension cables crossing the hazardous
area?
Have you identified how you will remove rubbish created by your work so the
site remains tidy?
Are energy sources isolated and locks and tags applied?
Are transfer and / or dispensing pumps shut down with the valves closed?
Does the work team have the correct PPE for the task?
Does the work team understand the hazards, risks and controls?
Have you communicated what work is going to be carried out, including risk,
precaution and any out of bounds area to the Site Representative?
Confirm you are familiar with Z Life Saving Rules and have advised your workers
including subcontractors
List any additional site specific hazards (e.g. Tanker delivery, delivery of food goods, etc.):
List any additional controls to be taken (e.g. PPE, barricading, etc.):
3.
CONTRACTOR CARRYING OUT THE WORK – CONTRACTOR
The person undertaking the work acknowledges that the job will be undertaken in accordance with the controls listed above and the Z Life Saving Rules, all work will be completed in a safe
manner, and that the Site Representative will be informed of any changes in risk, any suspension of work and any accidents.
NAME:
SIGNATURE:
TIME:
DATE:
Worker(s) Names: Add on the back of form
if more room is required
4.
ACKNOWLEDGEMENT OF WORK – SITE REPRESENTATIVE (operating locations only)
The Site Representative witnesses the contractor's signature, and agrees to inform the contractor of any change in site conditions such as tanker delivery.
NAME:
5.
SIGNATURE:
TIME:
DATE:
WORK CLEARANCE CLOSE OUT – CONTRACTOR
The Contractor acknowledges that the job has been completed/suspended and the site has been left in a safe and satisfactory condition.
NAME:
6.
SIGNATURE:
TIME:
DATE:
WORK CLEARANCE CLOSE OUT – SITE REPRESENTATIVE (operating locations only)
The Site Representative acknowledges that the Contractor has departed and closed out WCF (5. Above).
NAME:
SIGNATURE:
TIME:
DATE:
Last updated 13th May 2014